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Health Protection Fund - Year V: 1997


This report represents an ongoing evaluation of the Massachusetts Health Protection Fund Grant Program. The Health Protection Fund (HPF) was established through a 1992 state legislative referendum that directs a portion of tax revenue on tobacco products to the Department of Elementary and Secondary Education for tobacco prevention education and cessation through comprehensive school health education programs. The 1993 school year was the first year school districts received the grant. All school districts in the Commonwealth are eligible to receive the HPF grant and more than 95% of districts do so each year. For 1997 there was a minimum award of $12,000 per district, with additional funds allotted to school districts based on $24 per pupil. Over the five years from the 1993 school year through the 1997 school year, approximately $117,000,000 has been distributed through the Health Protection Fund to school districts in Massachusetts for PreK-12 comprehensive school health education programs. Other agencies that receive and distribute Health Protection Fund monies in various ways include the Massachusetts Department of Public Health for Tobacco Control Programs and Enhanced School-Based Health Centers and the Massachusetts Office of Public Safety for SAFE and DARE programs. According to the Centers for Disease Control, "state tax increases are more effective when combined with a comprehensive tobacco prevention and control program".1

Goals of the Evaluation of the Health Protection Fund.

The goals of the Year V Health Protection Fund Evaluation (1997 school year) were to:

  • Document the extent to which districts are following a comprehensive school health education model (CSHEP), including having a tobacco-free schools policy, tobacco prevention education programs, and tobacco cessation programs.
  • Identify the comprehensive school health education program practices and activities related to reductions in tobacco use in adolescents.
  • Identify the comprehensive school health education program practices that are related to reductions in the adolescent risk behaviors of alcohol use, marijuana use, and violence.
  • Determine the extent of similarity of such findings from Year IV to Year V.
  • Discern patterns of the most effective CSHEP practices as related to reductions in student risk behaviors.

The purpose of a comprehensive school health education program.

In Massachusetts, through health literacy, self-management skills, and health promotion, comprehensive school health education programs teach fundamental health concepts and promote habits that enhance health and wellness. Risk behaviors can substantially jeopardize the health and wellness of students as well as having a detrimental impact on school performance. 2, 3,4 Schools are seen as a vital and efficient setting in which to teach about health, including the need of students to develop independent thinking and decision-making skills. 5, 6

As a part of the HPF grant, school districts are expected to know the extent to which their students engage in risk behaviors and use this information to plan their comprehensive school health education programs. Four risk behaviors in particular tend to be the most common that youth engage in and are therefore of the most concern and most consistently measured by school districts. These are tobacco use, alcohol use, marijuana use, and violence in the form of physical fighting. The evaluation includes all four behaviors. Research also shows that risk behaviors tend to cluster together. 7, 8 For example, the 1997 Massachusetts Youth Risk Behavior Survey found that compared to students who had not smoked cigarettes in the past month, students who did smoke were more likely to report alcohol and illegal drug use as well, especially marijuana, and students who used alcohol were more likely to have been involved in physical fighting. While students still engage in risk behaviors at unacceptable levels, fortunately within the Commonwealth, physical fighting has decreased since the first year of HPF, and the behaviors of recent cigarette smoking, recent marijuana use, and heavy alcohol use, that had been increasing in the early nineties, have leveled off. Evaluations of comprehensive school health education programs nationally have found such programs to be related to decreased risk behaviors and increased well being, which in turn has promoted better school performance 9,10,11 The current HPF evaluation identifies specific program practices that are related to decreases in risk behaviors in some Massachusetts school districts.

The components of a comprehensive school health education program. There are several vital components that together make up a comprehensive school health education program. Classroom-based health instruction by health teachers, physical education teachers, and family and consumer sciences teachers provides exposure to the health curriculum and the learning of health knowledge and skills. The teachers of academic subjects make an important contribution to comprehensive school health education programs through interdisciplinary instruction that can broaden and deepen students' understanding of health topics. Support services enable students to receive health-related services, reinforce learning that takes place in the classroom, and provide additional learning in health education. These support services include health services, counseling and psychological services, peer activities in health education, and parent involvement and community participation in health education programs. Evaluating comprehensive school health education programs on the local level to inform and improve the program is a useful practice as well.

The context in which to interpret findings. The program components discussed above are represented among the findings presented in this report of effective program practices in a sample of Massachusetts comprehensive school health education programs and reductions in student risk behaviors. Additionally, there is support in the research literature for the findings reported here. In particular, a series of protective factors in keeping students healthy and well functioning that has been well established in the literature also appears to be operating here; namely, school, family, community, and individual factors. 12, 13

It is important to note that these findings are associations and should not be interpreted as cause and effect statements. Due to the fact that these analyses are based on a program that has only been in place a few years and is just now yielding outcome data, the analyses are necessarily still exploratory. However, as there was similarity of these finding from the previous Massachusetts Health Protection Fund evaluation14, it is with growing confidence that these findings are presented. The most clearly interpretable findings were chosen to be highlighted. All findings are available in the appendices. The evaluation report is organized into Methodology, Findings, Recommendations, References, and Appendices.


Design and Analysis

Data on comprehensive school health education programs in Massachusetts were used to study program practices (see Appendix A). The survey that yielded the district level data for the Year V Health Protection Fund Evaluation (1997 school year) was designed based on the findings of the Year IV Health Protection Fund Evaluation (1996 school year).

Year IV was the first time that the HPF evaluation focused on the relationships between program practices and student behavior outcomes. In order to be included in the data set to be used for the analysis of these relationships in the Year V evaluation, school districts needed to have available student behavior-based needs assessment data with rates for these risk behaviors from the 1993 school year (the beginning of Health Protection Fund grant program, Year I) and from the 1997 school year (Year V). The difference between the two rates gave the change in risk behaviors as an outcome measure. These districts therefore have pre-post outcome data. A decrease means that the rate in Year V was lower than the rate in Year I.

The behavior rates reported by districts with pre-post outcome data on the local level for Year I and Year V were compared to the rates from two large randomly selected surveys done in Massachusetts, the Youth Risk Behavior Survey (conducted by the Department of Elementary and Secondary Education) and the Health and Addictions Survey (conducted by the Department of Public Health) during these years (see Appendix B). The local rates reported by districts tended to be similar or a little lower than those of the Youth Risk Behavior Survey and the Health and Addictions Survey. This same pattern was also present for the local rates reported by districts in the previous evaluation.

These data were first analyzed for relationships between individual program practices and the behavioral outcomes. The relationships between individual program practices and reduced risk behaviors from this phase of the analyses were then compared to findings from Year IV to determine the degree of similarity and replication.

Next, statistical models of groups of program practices were generated from the individual program practices to provide the best understanding of the decreases in risk behaviors while also being practically meaningful. These statistical models include the program practices that together best explain the decreases in the risk behaviors of tobacco use, alcohol use, marijuana use, and engagement in violence (see Appendix B). The current evaluation is the first time this approach has been used.

Separate data for middle school and high school behavior rates were collected in the Year V evaluation, rather than combined rates as in the Year IV evaluation. Additionally, the risk behaviors were more clearly defined on the Year V survey. Tobacco use, alcohol use, and marijuana use refer to any use within the last thirty days, and violence refers to having been in a physical fight in the last 12 months. Program practices in the current report refer to those in place during the Year V school year and are an extension of data collected on these program practices during the Year IV school year.

More specific information on the methodology, including sample sizes, the survey, frequencies for program practices, inferential statistics, and additional information about the design and analyses is located in Appendices A and B.


The Findings section first shows the percent of funds in the designated budget categories of the Health Protection Fund grant for Year V as well as the average of the previous years. This section also presents information on spending for tobacco education prevention and cessation during Year V.

Next, general comprehensive school health education program descriptive information is presented.

The Findings section is then organized into the categories of Exposure to Health Curriculum, Involvement of Important Others, and Local Program Evaluation and presents:

  • individual health education program practices significantly related to decreased risk behaviors, and
  • comparison of the current evaluation findings (Year V) with last year's findings (Year IV).

In moving forward in this phase of the evaluation of the HPF, an additional analysis was conducted. The last section presents groups of effective program practices organized by the student risk behaviors.


The pre-post outcome data were checked for relationships with several demographic variables due to concern that other variables might provide alternative explanations for the findings. There were no relationships between the outcomes and:

  • kind of community (urban, suburban, rural),
  • district enrollment,
  • amount of Health Protection Fund monies a district received, or
  • amount of other health-related grant monies (e.g., Safe and Drug Free Schools, Health Protection Fund Mentors, School and Community, Teen Dating Violence, After School, Safe Schools for Gay and Lesbian Students) a district received.

Therefore, the outcomes do not appear to be present as a function of kind of community, number of students in the district, nor the amount of Health Protection Fund monies or other health-related grant monies received by a district.

The districts with pre-post outcome data were compared to the remaining districts that provided program practices but did not have pre-post outcome data on several demographics. These two groups appear to be very similar. These demographics are kind of community, the average enrollment for the district, middle school and high school, the average number of middle and high schools, the average 8th and 10th grade English Language Arts, Math, and Science Massachusetts Comprehensive Assessment System (MCAS) district scores, the average percent of students eligible for free and reduced lunch, and the average percent minority for the district (see Appendix B).

Section A: Funding: Health Protection Fund Budget Category Spending

The total amount of the Health Protection Fund for Year V (1997 school year) for all districts that participated in the grant program was $21,058,473. The monies were allocated in the following way within districts:

 Average- Years I-IV
Average- Year V
Instructional/Professional Staff53%56%
Contractual Staff17%11%
Support Staff 5% 10%
Supplies and Materials9%4%
Equipment, Travel, Fringe Benefits, and Indirect Costs 5% 4%

Overall, there has been little change over the course of the Health Protection Fund Grant in the percent spent in the categories above. For example, most of the monies have continued to be designated for staff who provide instruction or services. There has been a slight rise in the percent used for administrative costs. This could be due to an increase over time of having a health coordinator in place, and/or paying the health coordinator as health coordinators sometimes fulfill the duties without pay. The percent for contractual staff has decreased, which could be a result of less training by outside consultants as the program staff has become more experienced, or due to hiring more permanent staff to provide instruction and services. The increase in monies for support staff could also reflect less reliance on contractual staff, or could reflect support staff working with the permanent health staff as they take on the additional duties of health coordinator. Supplies and materials having already been purchased in the earlier years of the grant may account for the decrease in this area.

A priority of the Health Protection Fund grant is a focus on tobacco prevention education for all students. Districts reported spending approximately 17% of the Health Protection Fund grant monies they received exclusively on tobacco prevention education and cessation.

Section B: General Comprehensive Health Education Program Description

Findings in Section B are based on the 277 districts that returned surveys (see Appendix A).

Health Coordinators

Health coordinators were paid to work in this capacity an average of 18 hours per week. Many had additional duties as well. For example, approximately 54% taught health courses/classes. Including the health coordinator, districts had an average of 5 health teachers. According to the most recent Massachusetts Department of Elementary and Secondary Education School Health Education Profile Report (1998)15, the majority of lead health teachers received their professional training in either health education or both health and physical education. The evaluation found that health coordinators have held the position for an average of 5 years, either in their current district or in any district. This is the length of time the Health Protection Fund Grant program has been in place, which requires a PreK-12 health coordinator to oversee program implementation.

Health Education Received and Required K-12

Students received the following number of hours of health education per year.

Current ReceivedCompared to Last Year Current Received Compared to Last Year
K-5th / 27hrs not available 9th 33hrs / 10hrs less
6th / 32hrs same hrs 10th 26hrs / 7hrs less
7th / 33hrs 5hrs less 11th 21hrs / same hrs
8th / 33hrs 2hrs less 12th 18hrs / 1hr more

Students were required to have the following number of hours of health education per year.

Current RequiredCompared to Last YearCurrent RequiredCompared to Last Year
K-5th / 17hrs not available 9th 34hrs / 6hrs less
6th / 23hrs 5hrs less 10th 27hrs / 2hrs less
7th / 27hrs 7hrs less 11th 11hrs / same hrs
8th / 28hrs 4hrs less 12th 6hrs / 1hr less

The number of hours that students received health education did not quite meet the number of hours they were required to have health education in grades 9 and 10. Looking within middle school, the 8th grade, and within high school, the 10th grade, had the closest match between received and required hours of health education. Overall, there was a drop from last year to this year in both the number of hours received and required in health education. At both times, in high school, the 9th grade was where students received the greatest number of health education hours. However, the 9th grade was also where in Year V there was the most substantial reduction in hours of health education. For reduction of received hours and reduction of required hours in middle school and high school, the two grades prior to the MCAS testing (7th and 9th) showed the greatest reduction of hours. The low number of hours in the last two grades of high school may be due to the fact that in a substantial number of districts health is neither received nor required.

An average of 56 hours minimum of health education was required for graduation from high school. Last year, 71% of districts required completion of at least one health course for graduation.

How Health Education Was Delivered

Students received health education in the following settings. Students may receive health education in more than one setting.

 Elementary SchoolMiddle SchoolHigh School
Through Health Classes 47% 71% 69%
Through Physical Education Classes 18% 16% 20%
Through Non-Health Classes (e.g., Academics) 35% 13% 11%

Students received the majority of their health education in health courses or classes, followed by physical education classes and non-health classes, which were similar in amount. However, in elementary school, there was more delivery through non-health than in middle school and high school. This may most likely be accounted for by the fact that the regular classroom teacher provides much of the health instruction at the elementary level.

Tobacco-Free Schools Policy and Cessation

The districts' tobacco-free school policies included the following consequences for student violation (some districts have more than one of the consequences listed below):

92% include that students are suspended or expelled,
72% require students' parent/guardians to meet with school officials,
48% include that students must participate in prevention education,
29% include that students must participate in cessation program, and
14% include that students are fined.

Percent of Districts that Offered Cessation Programs in the Last 12 Months

63% of districts offered cessation programs for students,
29% of districts offered cessation programs for staff, and
23% of districts offered cessation programs for parents and community members.

Average Number of Hours for the Tobacco Cessation Program

10 hours for students,
8 hours for staff, and
9 hours for parents and community.

Number of Participants within the Last 12 Months (range)

For students, 13% of districts that had cessation programs reported no participation. Between 1 and 18 students participating was reported by 51% of districts, between 18 and 38 students by 21% of the districts, and between 40 and 80 student participants by 12%. The remaining 3% of districts reported that the number of participants ranged from 40 to 157 students.

For staff, 55% of districts that had cessation programs reported no participation. Between 1 and 12 staff participating was reported by 44% of districts. One district reported that 30 staff participated.

For parents and community members, approximately 40% of districts that had cessation programs reported no participation. Between 1 and 23 parents participating was reported by 35% of districts. The remaining 25% of districts reported between 24 and 100 parents and community members participating.

Of those Participating, Percent that Completed the Cessation Program

61% of students completed the cessation program,
33% of staff completed the cessation program, and
47% of parents and community members completed the cessation program.

The number of hours for sessions for students, staff, and parents/community was very consistent. Overall, completion rates were low. Paralleling participation, staff completion rates were only a third, and less than half of the parents/community participants completed the program. Students had the best completion rates, approximately sixty percent of students who participated completed the tobacco cessation program.

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Last Updated: October 1, 1999
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